- Date
- 8/31/2024
- Report number
- 00352144-AP-302429
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is known to walk around the facility and to try to get other residents to walk with AV when AV is feeling anxious. AV has scheduled and PRN Lorazepam available to AV. AV utilizes this medication frequently for extreme anxiety. There is nothing in AV’s care plan that states what staff are to do regarding AV’s anxiety. There is nothing in writing for staff to refer to regarding AV’s anxiety and any interventions that can be done to mitigate the risk of an altercation with another resident. W1 is known to not like being touched by residents or staff. W1 has severe hallucinations. AV and W1 have history of one negative interaction that occurred in July 2024,AV was trying to get W1 to walk with AV and W1 said no. On or about August 31, 2024, AV wandered into W1's room and attempted to get W1 to walk with AV. W1 pushed AV to the ground and yelled that W1 was done being touched by AV. Staff separated AV and W1 and helped AV off the ground. AV sustained an injury, and redness was noted to AV's back between the shoulder blades. AV was noticeably anxious throughout the day leading up to this event with W1. Staff had successfully kept AV occupied throughout the day by walking with AV to keep AV from engaging in any negative interactions with other residents. The event with W1 occurred when staff left AV alone while AV was feeling extreme anxiety. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing behaviors/anxiety, and failed to provide clear direction to staff on providing services to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00127 $375.00 fine assessed